how patient medical records can connect people to non-medical community services
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hamilton health sciences' social prescribing program embeds patient needs in the electronic medical records system and helps connect them to community resources, such as housing, food security, employment and wellness activities.
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growing up, rochelle reid remembers one of her public school teachers telling her that she was “surprisingly articulate for a black student.” when she told her parents, they asked what she said in response. “nothing,” she says of her silence. rochelle was 10 years old in grade 5, and a first-generation canadian of jamaican descent living in cambridge, ontario—a very small town at the time with few black residents.
her parents went to the school together to address the teacher, and when they came home, they gave her guidance that she would carry through her youth and career:
“people will think less of you because of the colour of your skin. in order to get ahead in this country, you have to go above and beyond and use your voice to make the change you want to see.”
as rochelle says, “i certainly have my parents to thank for my foundation, because they’ve always instilled in me, my brother, my sister, that your voice is your power and you have to use your voice and speak up. and when you see that something is not right, you need to speak up.”
and she has. a recent mba graduate with a focus on digital transformation, rochelle works for hamilton health sciences (hhs), an academic and research hospital for residents across southwestern ontario. it serves a diverse population, including many newcomers, where bridges are needed to address critical care gaps. this is exactly what she tackles as the hospital’s chief health equity officer.
rochelle is a driving force behind the hhs’s social prescribing program. the program, based on work by the alliance for healthier communities, embeds patient needs in the electronic medical records system and helps connect them to community resources, such as housing, food security, employment and wellness activities.
the aim is to deliver truly holistic care that meets both medical and social needs, particularly important for people who face language, sociodemographic and technological barriers, rochelle notes. she can relate to feeling isolated and excluded, so she wants healthcare that serves everyone.
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“we’re seeing a lot of people come into our hospitals that certainly need supports, but the hospital maybe isn’t the right place for them. however, they maybe don’t know where else to go. perhaps the hospital is the only place that’s open at the time,” she says of the hhs system that employs more than 18,000 people in seven hospitals, a cancer centre and a number of satellite sites.
novartis canada selected hhs to receive a portion of its $562,000 grant as part of the 2025 health equity initiative. shared with two other canadian programs, the funds support patient data collection and expansion of the social prescribing program.
social prescribing transforms patient experience
“so with social prescribing, it actually gives us a pathway to be able to support the patient or the individual that is coming in and do it in a way that aligns with our systems and the business that we’re in.”
before the initiative began, people would come into hhs and not always find the help they needed or know where to turn. now, care providers can refer patients to non-medical community resources.
“when we think of healthcare and providing care for patients, it’s really not just on a symptomatic level. people come in as whole people, so understanding who our patients are from a holistic perspective, having that information and being able to provide holistic care will mean better health outcomes for canadians.”
as well, the program champions patient-centred care, and is part of a five-year plan under rochelle and her team that began with a focus on relevant data. “we’ve really started to dig into data collection and ensuring that we’re collecting the proper data, particularly around health equity and social determinants of health, to be able to understand exactly who our patients are and what the disparities are within our hospital.”
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beyond scientific literature surrounding health equity, she recognizes the need to connect the dots and understand locally what is happening within hhs.
she also notes that the overarching aim for equity and inclusion is powerful and resonates deeply with her personal experiences.
“there have certainly been times growing up where i was either singled out or left out. and that feeling as a child never leaves you,” she says of her early days that fuelled her determination to help others. before joining hhs, rochelle worked in higher education to promote equity and access, and clearly does her part.
during that time, she took a solo pleasure trip to jamaica and, by happenstance, went to visit her mom’s former primary school in a rural area. the school team was excited to show her around. “they were like, ‘this is our nursing station.’ and it was just a mattress on the floor. ‘this is our computer room,’ with no computers.”
the visit was a catalyst for her returning to canada and recognizing that she worked at an institution that gave people new laptops every year.
rochelle went on to create a global work-integrated learning experience where canadian students had the opportunity to go to the school in jamaica, donate refurbished laptops and work to reconstruct the school to bring those young kids better access to education.
“we had the computer engineering students come and do the networking and facilitated workshops for those students and the teachers, and started to do some initial work around coding and things like that. we also had construction engineering students go down a couple of months later and they completely revitalized the school. they redid the kitchen, they created a new library, they renovated the classrooms, and all of that was done through donors,” she says.
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“it was just a transformational experience.”
groundwork for community engagement
community engagement is still a focus in the work rochelle is fired up to continue with hhs. social prescribing, with funds from novartis, will expand the capacity to build community partnerships that solve the disconnect in what a hospital does, what a community centre does and what other community supports provide.
“we are all serving the same patient population, so we need to have better connections with those that are doing the work on the ground. and that is precisely what social prescribing does. it enables us to develop those partnerships to connect patients with our community partners by providing non-medical prescriptions or referrals.”
it comes back to people, understanding their needs and including everyone in solutions. as rochelle says, “it’s not just transforming the system, it’s truly transforming the lives and the well-being of people. that, for me, is what does it.”
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